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1. Abdominal Vascular Injuries
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2. Overview
• Among most lethal injuries
• Hemorrhage (free or contained), thrombosis, or combination
• Intraperitoneal hemorrhage, a contained mesenteric, retroperitoneal,
portal hematoma
• Management: NOM, endovascular, operative

3. Anatomy: Retroperitoneal Hematoma
• Zone 1: midline
• Supramesocolic
• Inframesocolic
• Zone 2: upper lateral
• Zone 3: pelvic
• Zone 4: Portal

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Reuver/5a624713512f98ec11c0838e8093e13efb3e1ad4/figure/0

6. Pathophysiology
• Blunt
• Rapid deceleration
• Avulsion from fixed part: hemorrhage
• Intimal tear: secondary thrombosis
• Crush injury: compression and thrombosis-forming
• Direct blow: exposed vessel disruption and bleeding
• Penetrating
• Wall defect and transection: either bleeding or thrombosis
• Blast effect
• AV fistula

7. Diagnosis: History Taking and Physical Examination
• Presentation: Based on whether ongoing hemorrhage or not
• Ongoing:
• Hemorrhagic shock
• Without:
• Abdominal pain
• Flank pain
• Hematuria
• Pulseless lower extremities

8. Diagnosis: Imaging
• FAST is recommended
• In VS stable:
• Penetrating: AXR to track the missiles
• Blunt: CT whole abdomen

9. Initial Management and Options
• Since prehospital field: IV resuscitation
• ER: ATLS, consider REBOA or RT
• Options for definitive management
• NOM: NOT every injury should undergo stent or embolization
• Endovascular may be appealing in
• Severe associated injury: brain, burn, organ failure
• Hostile abdomen
• Delayed diagnosis
• Failed operative repair
• Open surgery: classic

10. Operative Preparation
• 1:1:1
• Draping from chin to knee, both arms abduct 90O
• Incision: long midline from xiphoid to pubis
• Evacuate clot
• Rapid inspection for hemorrhage/hematoma area
• Standard vascular control used for active hemorrhage: digital
pressure, swab packing, grabbing, formal proximal and distal control,
sponge sticks, vascular clamp

11. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

12. Mattox KL et al. Trauma. 8th ed. McGraw-Hill Medical, 2017.

13. Management of
Specific Vascular Injuries by Zone

18. Summary Algorithm
Blunt Penetrating
zone1 Open Open
zone2 Not Open
zone3 Not Open
Portal
retrohepatic
Open
Not
Open
Not

20. Venous Injuries
• Temporary Control by sponge sticks compression
• Most can be ligated if extensive
• Infrahepatic IVC
• Look for posterior perforation by visualize from anterior hole and repair with first knot outside
• Look for signs of compartment syndrome if narrowing
• SMV: ligate and open abdomen
• Renal vein: repair or ligate
• Rt: nephrectomy
• Lt: medial can be ligated without nephrectomy if patent gonadal and adrenal v.
• Portal vein: ligate only if so extensive
• Retrohepatic IVC: Don’t open Pandora’s box!!
• Common iliac veins: repair or ligate
• Ligation: well-tolerated in the young

21. Complications
• As in other vessels
• Thrombosis or occlusion
• Dehiscence of suture line
• SMA and associated pancreatic injury
• Enteric contamination
• Infection
• Vascular-enteric fistula: cover suture lines with retroperitoneal tissue
or omentum

22. Take Home Message…
• Retroperitoneal hematoma: 3 – 4 zones
• Most penetrating injuries: open hematoma
• Blunt injuries: Do Not open hematoma unless exanguinate in Zone 2,
3
• Proximal aortic control: REBOA, RT, supraceliac clamp
• Most arterial injuries: try to repair except celiac trunk (ligation)
• Most venous injuries: repair or ligation and monitor sequelae

23. References
• Mattox KL et al. Trauma. 9th ed. McGraw-Hill Medical, 2020.
• Feliciano DV, Moore EE, Biffl WL. Western Trauma Association Critical Decisions in Trauma:
Management of abdominal vascular trauma. J Trauma Acute Care Surg. 2015 Dec;79(6):1079–88.
• Demetriades D, Inaba K, Velmahos G, editors. Atlas of Surgical Techniques in Trauma [Internet].
2nd ed. Cambridge: Cambridge University Press; 2020 [cited 2021 Dec 4]. Available from:
https://www.cambridge.org/core/books/atlas-of-surgical-techniques-in-
trauma/F4D71F1067897354BE195DC1A9B3D19A
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